What is a Care Plan for the Elderly at Home?
What should families receive in writing?
The map is clearly drawn, so everyone in the house is looking out the same way.
According to the definition of the Department of Health.
NICE NG21 Guidelines, United Kingdom
Ministerial Regulations B.E. 2563
Cochrane 2015 · 10,856 people
Many families describe the caregiver's job description verbally, and when the caregiver changes, they have to start explaining it all over again.A well-written care plan ensures everyone is on the same page and knows when to call the support team.
General information as of October 2026. Each individual's plan must be based on an assessment from the team that is actually overseeing them.
The content in this article
1. Care Plan: What is a care plan for the elderly, and who creates it?
Short answer:A Care Plan is an individualized care plan written based on an assessment of the elderly individual. In the government's Long-Term Care (LTC) system, the Department of Health defines it as a collaborative effort between the Care Manager, a team of specialists, and the family. Caregivers then follow the plan.
- Care Manager(Public Sector Long-Term Care (LTC) System) Manages, coordinates services, and develops Care Plans.
- CaregiverIn the public sector, operations are overseen by professionals; private services should specify the name of the supervisor in the plan.
- familyState your goals, participate in decision-making, and report any changes in symptoms.
A letter from the Department of Local Administration dated March 19, 2026, states that Care Managers, local volunteer caregivers, ADL assessments, and Care Plans are part of the local responsibilities for caring for dependent elderly individuals.Private services do not need to use the same forms as the government system.But the principle is the same: assessment first, someone responsible, and periodic reviews. This is an overall overview of reading management.A guide to quality elderly care.
At-home assessments: Listen to both the elderly person and their family.
2. What assessments should be made before writing a Care Plan?
Short answer:Assess the ability to perform daily activities (ADL), chronic diseases and medications, swallowing, skin, fall risk, cognitive function and emotions, home conditions, and things the elderly person wants to do independently.
- daily routineHow capable are you of eating, showering, getting dressed, using the toilet, walking around, and being self-sufficient? Read how to measure it here.Assessing ADL using the Barthel Index.
- Risks and equipmentChoking, falling, pressure sores, medication, feeding tube.
- Things that elderly people want to be able to do.Use it as the goal of the plan.
- People in the houseWho is in which stage? Who makes the decisions? Who is starting to get too tired?
3. What topics should a good care plan include?
Short answer:At a minimum, the plan should include goals, routines for assistance, medications, risks and mitigation methods, signals to alert the team, an emergency plan, family responsibilities, responsible persons, and plan review dates. It should be easy to read and include a summary on the first page.
| section | What do I need to write? |
|---|---|
| Summary of the first page | Primary medical conditions, drug allergies, emergency contacts, primary hospital. |
| target | What can I achieve, and how can I measure improvement? |
| Routine and medication. | Eating, swallowing, defecating, turning over; Name of medication, what it's used for, dosage and method of administration as directed by a doctor, time, who administers it. |
| Risk | Falls, choking, and pressure sores: ways to reduce the risk. |
| When the symptoms change. | Which symptoms should you report to the team? Which symptoms require calling 1669? Which hospital should you send the patient to? |
| Who did what? | Family responsibilities, coordinator's name, contact number, review date. |
Summary of NICE NG21 (2015) guidelines, sections 1.3.13–1.3.16, adapted for home care in Thailand.
A medication plan is not about adjusting medication.Take medication as prescribed by your doctor. Do not increase, decrease, or stop medication on your own. If you have any questions, ask your doctor or pharmacist. Read more at...Elderly people take many medications.
Handing over the work plan in front of the family.
4. Before beginning home care, the family should have a written agreement on what to expect.
Short answer:According to NICE, clients or caregivers should receive a copy of the home care plan and maintain a care diary at home. The current medication list, caregiver scope of duties, and service agreement are checklists recommended by KIN for clarity, not mandatory under NICE or Thai law.
- Copy of Care PlanIn a format that families can understand (NICE recommends that clients have a copy of the plan).
- Daily care logbookKeep a record at home, documenting every day, including any changes in symptoms.
- Current medication listandScope of work for the administrator.The team will assess and clearly identify which tasks require a registered nurse.
- Terms of ServiceWork hours, caregiver changes, who is authorized to receive health information... Read more at...7 risks to consider before hiring a home caregiver for the elderly.
5. When should we review our Care Plan?
Short answer:The UK's NICE NG21 guidelines (not Thai law) recommend an initial home care plan review within 6 weeks, followed by regular reviews at least annually. For healthcare facilities caring for the elderly or dependent individuals in Thailand, ministerial regulations require assessments of care needs and communication abilities upon admission and subsequent assessments every 3 months. This requirement does not apply to all home care services and should be reviewed immediately upon change in symptoms.
Review immediately when...Recently returned from the hospital or changed medication; fell; choked more often; eaten/drank less; new pressure sores; more confused or withdrawn than before; changed caregiver or family members are unable to cope.
A notebook helps indicate when to review the plan.
"A good plan doesn't have to be long, but it needs to be a plan that everyone in the household can read and follow, and they know when to call the team."
6. How helpful is a care plan, and what can't it replace?
Short answer:Cochrane found that individualized care planning with patients yielded small benefits for some outcomes. The effects appeared greater when the process encompassed multiple steps, involved more frequent team contact, and was linked to routine care. However, the differences between interventions and outcomes were not sufficient to support a single blueprint for all groups, and the plan did not replace emergency care.
Coulter et al. (Cochrane, 2015) compiled 19 studies involving 10,856 people, 12 of which included diabetic patients. They found small positive effects on some outcomes such as HbA1c, systolic blood pressure, depression, and self-efficacy. This evidence did not directly study bedridden elderly individuals at home and does not endorse any particular Care Plan.
No need to wait for plan review, call 1669 immediately, for example, when...
• Difficulty breathing, choking to the point of suffocation, unconsciousness, chest pain, seizures.
• Facial asymmetry, weakness or paralysis on one side of the body, and sudden difficulty speaking.
• If they fall and hit their head, then become drowsy or vomit, do not rush to help them up.
How did KIN help the family?
KIN HomeCare provides home-based care for the elderly and sick. Our team of professional nurses assesses, plans care, and discusses the care with the family.It contributes to making home care more systematic.
- Registered nurse visits home.Assess the symptoms, create a care plan in writing, and instruct the family.
- Home caregiver (NA)12-hour shifts or 24-hour shifts with breaks, nationwide. View profiles first.
- Home Physical TherapyFor Bangkok and surrounding areas only.
- Rent medical equipmentExamples include electric hospital beds, wheelchairs, and oxygen concentrators.
Consult KIN HomeCare | Plan home care for your elderly loved ones.
If you would like a Care Plan document before starting care, please consult with the nursing team.
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Central hotline:02-096-4996In case of emergency, call 1669.
Frequently Asked Questions answered by the KIN medical and multidisciplinary team.
What is a care plan for the elderly?
A personalized care plan is written based on an assessment of the elderly person. It outlines the goals, tasks to assist with, risks, and review dates.
Who creates the care plan? Can the caregiver create it themselves?
This should be planned by the Care Manager or nurse in collaboration with the family. The caregiver follows the plan and records their findings.
What should a care plan include?
The first page should include a summary of goals, routine and medications, risks, plan for symptom changes, responsible person, and review date. The details should be adjusted based on individual assessments.
How often should you review your Care Plan?
The NICE NG21 regulation from the UK, which is not Thai law, recommends reviewing the home care plan for the first time within 6 weeks and at least annually thereafter. The Thai regulation regarding 3 months applies to needs assessment and communication in the types of establishments covered by the law, not all home care services. Furthermore, the plan should be reviewed immediately upon discharge from the hospital, a fall, or a change in medication.
What documents do I need to request when hiring a home caregiver for the elderly?
Copies of the Care Plan, daily logbook, medication list, caregiver's scope of duties, and service agreement.
Can I adjust my medication according to my Care Plan myself?
No. The plan states that you must take the medication as prescribed by your doctor. Do not increase, decrease, or stop the medication on your own. If you have any questions, ask your doctor or pharmacist.
- Standard Operating Procedures (SOPs) and performance indicators for elderly caregivers — Bureau of Elderly Health, Department of Health.
- A letter from the Department of Local Administration, dated March 19, 2026, regarding the inspection of care for elderly people with dependency issues.
- Ministerial Regulation prescribing standards for types of businesses providing care for the elderly or those with dependency needs, B.E. 2563 (Consolidated version, Department of Elderly Affairs)
- Home care: delivering personal care and practical support to older people living in their own homes — NICE NG21 (2558)
- Personalized care planning for adults with chronic or long-term health conditions — Coulter A and Cochrane et al. 2015
Medical accuracy verified by Dr. Chanya Wuttikraikul, License No. 51106, Geriatrics | Supervised by Dr. Thongchai Chokthanomsap, Chairman of the Executive Board | Last updated: October 2026 |Preliminary data as of October 2026 is not a diagnosis or individual medical advice. Care plans must be based on an assessment by the actual care team. Research figures are not the result of KIN patients' experiences.